EAPCI Position Statement on Invasive

Management of Acute Coronary Syndromes

during the COVID-19 pandemic

Alaide Chieffo (Chair) 1, Giulio G. Stefanini 2, Susanna Price3, Emanuele

Barbato4, Giuseppe Tarantini5, Nicole Karam 6, Raul Moreno7, Gill Louise

Buchanan8, Martine Gilard9, Sigrun Halvorsen 10, Kurt Huber11, Stefan James12,

Franz-Josef Neumann 13, Helge Mollmann14, Marco Roffi15, Guido Tavazzi 16,

Josepa Mauri Ferre17, Stephan Windecker 18, Dariusz Dudek19†, and

Andreas Baumbach (co-Chair) 20*†

1Interventional Cardiology Unit, IRCCS San Raffaele Hospital, Milan, Italy; 2Humanitas Clinical and Research Hospital IRCCS, Rozzano, Milan, Italy; 3Royal Brompton Hospital,London, UK; 4Department of Advanced Biomedical Sciences University Federico II, Naples, Italy; 5Interventional Cardiology Unit, Department of Cardiac, Thoracic, VascularSciences and Public Health, University of Padova, Padua, Italy; 6European Hospital Georges Pompidou (Cardiology Department) and University of Paris, Paris, France; 7CardiologyDepartment, Hospital La Paz and IDIPAZ, Madrid, Spain; 8Department of Cardiology, North Cumbria Integrated Care NHS Foundation Trust, Cumbria, UK; 9Service deCardiologie, Brest University Hospital, Brest, France; 10Department of Cardiology, Oslo University Hospital Ulleval, and University of Oslo, Oslo, Norway; 113rd Department ofMedicine, Cardiology and Intensive Care Medicine, Wilhelminen Hospital, and Sigmund Freud University, Medical School, Vienna, Austria; 12Department of Medical Sciences,Cardiology and Uppsala Clinical Research Center, Uppsala University, Sweden; 13Division of Cardiology and Angiology II University Heart Centre Freiburg, Bad Krozingen,Germany; 14Department of Cardiology St.-Johannes-Hospital Klinik fur Innere Medizin I, Dortmund, Germany; 15Division of Cardiology, University Hospitals, Geneva,Switzerland; 16Department of clinical-surgical, diagnostic and pediatric sciences, Unit of anaesthesia and intensive care, Fondazione Policlinico San Matteo Hospital IRCCS, Pavia,Italy; 17Hospital Universitari Germans Trias i Pujol, Badalona, Spain; 18Department of Cardiology, Swiss Cardiovascular Center, University Hospital Bern, Bern, Switzerland;19Institute of Cardiology, Jagiellonian University Medical College, Krakow, Poland and Maria Cecilia Hospital GVM, Cotignola, Ravenna, Italy; and 20Centre for CardiovascularMedicine and Devices, William Harvey Research Institute, Queen Mary University of London, Barts Heart Centre, London, UK and Yale University School of Medicine, NewHaven, CT, USA

Received 30 March 2020; revised 15 April 2020; editorial decision 23 April 2020; accepted 6 May 2020; online publish-ahead-of-print 14 May 2020

Abstract The coronavirus disease 2019 (COVID-19) pandemic poses an unprecedented challenge to healthcare worldwide.The infection can be life threatening and require intensive care treatment. The transmission of the disease poses arisk to both patients and healthcare workers. The number of patients requiring hospital admission and intensivecare may overwhelm health systems and negatively affect standard care for patients presenting with conditionsneeding emergency interventions. This position statements aims to assist cardiologists in the invasive managementof acute coronary syndrome (ACS) patients in the context of the COVID-19 pandemic. To that end, we assembleda panel of interventional cardiologists and acute cardiac care specialists appointed by the European Association ofPercutaneous Cardiovascular Interventions (EAPCI) and from the Acute Cardiovascular Care Association (ACVC)and included the experience from the first and worst affected areas in Europe. Modified diagnostic and treatmentalgorithms are proposed to adapt evidence-based protocols for this unprecedented challenge. Various clinical scen-arios, as well as management algorithms for patients with a diagnosed or suspected COVID-19 infection, presentingwith ST- and non-ST-segment elevation ACS are described. In addition, we address the need for re-organization ofACS networks, with redistribution of hub and spoke hospitals, as well as for in-hospital reorganization of emer-gency rooms and cardiac units, with examples coming from multiple European countries. Furthermore, we providea guidance to reorganization of catheterization laboratories and, importantly, measures for protection of healthcareproviders involved with invasive procedures.

� � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � �

Keywords COVID-19 • ACS • STEMI • NSTEMI • PCI

* Corresponding author. Centre for Cardiovascular Medicine and Devices, William Harvey Research Institute, Queen Mary University of London, Charterhouse Square, LondonEC1M 6BQ, UK. Tel: þ44 2036758740, Email: a.baumbach@qmul.ac.uk† These authors are to be considered as last authors.

This article has been co-published with permission in the European Heart Journal and EuroIntervention. All rights reserved. VC 2020 European Society of Cardiology. These articlesare identical except for minor stylistic and spelling differences in keeping with each journal’s style. Either citation can be used when citing this article.

European Heart Journal (2020) 41, 1839–1851 CURRENT OPINIONdoi:10.1093/eurheartj/ehaa381 Interventional cardiology

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.Abbreviations

ACS = acute coronary syndromeED = emergency departmentHCWs = healthcare workersNSTEMI = non-ST-elevation myocardial infarctionPCI = percutaneous coronary interventionPPE = personal protective equipmentSTEMI = ST-elevation myocardial infarction

1. Introduction

The coronavirus disease 2019 (COVID-19) pandemic is a majorburden on healthcare systems and is imposing a change in practicein multiple disciplines, including interventional cardiology. The cri-sis is showing a particular impact on the diagnostic and treatmentpathways for patients presenting with acute coronary syndromes(ACS).

Challenges for the networks include the strain on the hos-pital infrastructures, bed and catheterization laboratories (cath-labs) capacity, and transportation due to the number ofseverely ill COVID-19 patients admitted to hospitals. The po-tential COVID-19 infection status of each new patient has tobe considered to reduce the spread of the infection. The se-vere acute respiratory syndrome coronavirus-2 (SARS-CoV-2)has the same stability in aerosols and on surfaces as SARS-CoV-1, but the rate of transmission is higher.1 Its environmen-tal stability may contribute to the transmission of the virus inhospitals. It is therefore fundamental to guarantee proper pro-tection of healthcare workers (HCWs) for their own health, tominimize the risk of spreading the infection to other HCWsand patients, and finally to guarantee the proper level of carein cathlabs in the case of suspected or confirmed COVID-19patients.

Difficult decisions have to be made, taking into account the differ-ent stages of the pandemic in each country, region, and individualhospital. The European Association of Percutaneous CardiovascularInterventions (EAPCI) have assembled a panel of interventional cardi-ologists with first-hand experience from affected areas in Europe andexpertise in network organization, with support from authors fromthe Acute Cardiovascular Care Association (ACVC), experienced inthe treatment of severely ill patients with acute COVID-19 infection.

The objective of this position statement is to provide guidanceregarding optimal invasive management of patients with ACS duringthe COVID-19 pandemic whilst minimizing the risk of infection forboth patients and HCWs. This document reviews the clinical scen-arios in different phases of the crisis, reviews diagnostic difficultiesspecific to ACS presentations with raised troponins, proposes modi-fied algorithms for invasive management, re-organization of ACS net-works, hospitals, and cathlabs, and provides a guidance to maintainHCW safety during invasive procedures.

This statement is created as non-binding advice and does not inter-fere with any official local or national guidance in place. The advicegiven is valid only during the time of the COVID-19 pandemic, asdeclared by the World Health Organization.

2. Categorization of invasiveprocedures according to theirimpact on regional/nationalhealthcare services

The rearrangement of the healthcare service required to face theCOVID-19 pandemic has posed a series of relevant issues regardingprioritization of cardiac invasive procedures.2,3

Regions in Europe differ substantially in terms of local healthcareresources, pandemic density of the COVID-19 outbreak, changes ofthe pandemic over time, and therefore access to healthcare servicesother than COVID-19 care. These variations have a wide range ofimplications for national/regional healthcare services, national health-care authorities, and in-hospital redistribution of resources. Regions(also within the same country) may be categorized into three groupsaccording to the degree of involvement in the pandemic, with subse-quent different implications for the healthcare system, as summarizedin Table 1.

The indications provided in this document refer mainly to thescenario of heavy involvement and, in part, to the scenario of moder-ate involvement. Importantly, healthcare services should continue tobe provided according to standard of care as described by currentclinical practice guidelines,4 as long as the degree of regional involve-ment in the pandemic allows it. The rationale to importantly reducethe number of elective hospitalizations is three-fold: (i) to increasecapacity for COVID-19 patients; (ii) to reduce the unjustified expos-ure of individuals (i.e. patients in need of non-urgent procedures andtheir relatives) to the hospital and surrounding environment; and (iii)to reduce the exposure of HCWs to asymptomatic COVID-19patients.

This strategy comes at the expense of time-to-treatment delaysfor urgent cardiovascular interventions and extension of waitingtimes for patients in need of elective coronary, heart valve, or othercardiovascular procedures.

In this context, a strategy is needed to identify patients who arein a stable condition, therefore allowing a postponement of proce-dures, and those who are not. An obvious concern is to maintainthe standard of care and timely access of patients with ACS, includ-ing acute myocardial infarction (AMI), to reperfusion therapy. Inpatients with chronic coronary syndromes (CCSs), principles ofprioritization can be based on risk stratification, taking into accountthe prognostic implications of symptoms and the presence ofknown critical disease of the left main stem or of the proximal leftanterior descending coronary artery at prior coronary angiographyor at coronary computed tomography angiography (CCTA).4

Table 2 summarizes a categorization of invasive cardiac proceduresaccording to urgency that may be implemented in areas affected bythe COVID-19 pandemic.

3. Myocardial injury: the role ofcardiac biomarkers

Acute myocardial injury is defined as a rise and fall in cardiactroponin (cTn) with at least one value above the 99th percentile

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.upper reference limit (URL), attributable to cardiovascular ornon-cardiovascular causes.5 Implementation of high sensitivity (hs)-cTn assays, along with the application of the 4th Universal definitionof myocardial infarction (MI), has led to an increased accuracy in thedifferentiation between type 1 MI, type 2 MI, and acute and chronicmyocardial injury.6 However, no cut-off values for cTn can reliablydifferentiate between acute myocardial injury and different types ofMI. Whilst myocardial injury and type 2 MI are associated with aworse long-term prognosis than type 1 MI,7 there is no consensusregarding how to manage these patients, except for treatment of theunderlying disease.

In recent reports on patients hospitalized with COVID-19, 5–25%had elevations in cTn, with a higher prevalence in those admitted tothe intensive care unit (ICU) and also in those who died.8,9 Troponinelevation increased with COVID-19 illness deterioration and wasassociated with a worse prognosis.10 Interestingly, serum concentra-tions remained in the normal range in most survivors.10,11 Brain natri-uretic peptide (BNP)/N-terminal proBNP (NT-proBNP) levels arealso reported to be elevated in COVID-19 patients, particularly inthose with a concurrent troponin elevation.10,11 The concentrations

of BNP/NT-proBNP in a patient with COVID-19 should be seen asthe combination of the presence/extent of pre-existing cardiac dis-ease and/or the acute haemodynamic stress related to COVID-19 in-fection. The mechanisms underlying acute myocardial injury inCOVID-19 patients are poorly understood, and may include directviral and cytopathic effects, cytokine release syndrome potentiallyleading to microinfarction,12 type I MI (in patients with or withoutprevious coronary artery disease), type 2 MI in patients with severerespiratory distress/severe hypoxaemia, myocarditis,13 shock as partof COVID-19, or Takotsubo syndrome.14 The role of right ventricu-lar involvement in biomarker elevation remains to be determined. Inpatients with COVID-19 infection, the classical cardiac symptomssuggesting cardiac ischaemia may be misleading or absent, in particu-lar in those intubated and ventilated. A rise and/or fall of hs-cTn alonemay be insufficient to diagnose AMI, and ECG as well as echocardio-graphic parameters have to be integrated to target the most appro-priate management strategy.15,16

The use of coronary angiography for COVID-19-positive patientswith elevation in cTn should be restricted to those in whom type 1MI is suspected.

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Table 1 Regional involvement in the epidemic and impact on the healthcare system

Regional involvement in the epidemic

Marginal Moderate Heavy

Impact on the healthcare

system

None or minor restrictions in provi-

sion of regular healthcare services

Major restrictions in provision of

regular healthcare services

Inability to provide regular

healthcare services

....................................................................................................................................................................................................................

Table 2 Strategical categorization of coronary interventions during COVID-19 pandemic

Clinical condition EMERGENT (do not postpone) URGENT (perform

within days)*

LOWER PRIORITY

(perform within <3

months)*

ELECTIVE (may be

postponed >3 months)

Ischaemic heart

disease

• STEMI• NSTE-ACS in very high risk and

high risk patients• Cardiogenic shock

• NSTE-ACS in intermediate

risk patients• Unstable angina• Left main PCI• Last remaining vessel PCI• Decompensated ischaemic

heart failure• Angina pectoris class IV• CABG in patients with

NSTE-ACS unsuitable for

PCI

• Advanced CAD with an-

gina class III or NYHA III

symptoms• Staged PCI of non-IRA in

STEMI in patients with

haemodynamic stability

and without >90% lesions

in proximal segments of

major epicardial coronary

arteries• Proximal LAD PCI

• CTO interventions• CCS with angina class II or

NYHA II symptoms

Acute/chronic heart

failure

� Mechanical circulatory support

for cardiogenic shock (<65 years)

� Urgent heart transplant � LVAD

*Timing might be affected by overwhelming demand on resources in the setting of a COVID-19 pandemic.CABG, coronary artery by-pass grafting; CCS, chronic coronary syndromes; CTO, chronic total occlusion; IRA, infarct related artery; LAD, left anterior descending; LVAD, leftventricle assist device; LVEF, left ventricular ejection fraction; NSTE-ACS, non-ST-segment elevation acute coronary syndrome; NYHA, New York Heart Association; PCI, per-cutaneous coronary intervention; STEMI, ST-segment elevation myocardial infarction.

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.Troponin elevations in patients with COVID-19 infection seem to

be lower than in most cases of ACS or acute myocarditis. In the caseof marked elevation (e.g. >5 times the ULN) in a patient who is notcritically ill, myocarditis, Takotsubo syndrome, spontaneous coronarydissection, or type 1 MI should be suspected.

Key messages• Myocardial injury, as quantified by cardiac troponin T/I concentra-

tions, may occur in COVID-19 infections as in other pneumonias.The level of cardiac troponins correlates with disease severity andalso seems to have a prognostic value.

• Mild elevations in cardiac troponin T/I (e.g. <2–3 times the ULN),particularly in an older patient with pre-existing cardiac disease, donot require work-up for type 1 MI, unless strongly suggestive clin-ically by angina chest pain and/or ECG changes. Such mild eleva-tions are in general well explained by pre-existing cardiac diseaseand/or the acute injury/stress related to COVID-19 infection.

• Marked elevations in cardiac troponin T/I concentrations (e.g. >5times the ULN) may indicate the presence of severe respiratoryfailure, tachycardia, systemic hypoxaemia, shock as part ofCOVID-19, myocarditis, Takotsubo syndrome, or type 1 MI trig-gered by COVID-19. If no symptoms or ECG changes are suggest-ive of type 1 MI, echocardiography should be considered in orderto help diagnose the underlying cause.

4. Clinical scenarios

Both ST-segment elevation myocardial infarction (STEMI) and non-ST-segment elevation myocardial infarction (NSTEMI) can occur inpatients with a confirmed/suspected diagnosis or without signs orsymptoms of COVID-19. In order to select the appropriate manage-ment strategy, it is important to take into consideration the clinicalstatus of the patient and the likelihood of concomitant COVID-19.Whenever SARS-CoV-2 testing can be obtained before an invasiveprocedure, this strategy should be prioritized. However, in somecases, clinical presentation may require immediate intervention. Inthis case, or when COVID-19 is confirmed, every effort should bemade to reduce the risk of viral spreading with protective meas-ures17–19 that have to be implemented from the first contact with thepatient in the emergency department (ED) or in the out-of-hospitalsetting

i. It is critical to differentiate patients with type 1 MI from COVID-19patients, who might present with troponin elevation and/or STchanges, that are associated with respiratory symptoms and chestpain, without a coronary aetiology.3,12

ii. STEMI patients can be haemodynamically stable or present with car-diogenic shock (CS) or a mechanical complication. In the latter scen-arios, the need for advanced care should be assessed in the light oflocal resources and the patient’s age and comorbidities.Appropriate treatment should not be delayed, even if COVID-19 isconfirmed or suspected. Possible causes of delay in time to reperfu-sion are due to reluctance by the patients to call emergency num-bers, the late arrival of the ambulance to pick up the patient, andthen delayed time of arrival of the ambulance to the hospital due tocongestion and multiple calls because of the pandemic.Nevertheless, because of need for protection of other patients andHCWs, this may lead to further in-hospital delays.20,21

iii. Actions, such as public campaigns to raise awareness, dedicated lineswith an emergency number, dedicated ambulances for cardiovascu-lar emergencies, and entry points in ED with dedicated hospitalpathways (see Section 9), can be considered at appropriate stages ofthe pandemic aiming at reducing these delays. The initial experiencein affected areas suggests that as the infection spreads, there is aperiod characterized by low numbers of STEMI followed by a phaseof increased numbers of late presenters and related mechanicalcomplications.20

iv. The majority of NSTEMI patients do not have ongoing ischaemiaand respond well to medical treatment, allowing time to test thepatients for COVID-19 infection. Very high risk NSTEMI patientsshould be managed according to STEMI pathways.

v. Patients with out-of-hospital cardiac arrest constitute a group ofpatients in which prognostic assessment is of paramount importancein order to avoid futile intubation and ICU stay at a time of limitedresources. The threshold to bring out-of-hospital cardiac arrestpatients to ICU and to the cathlab (in the case of STEMI or very highrisk NSTEMI) depends on the capability of the hospital to admit thepatient and also the clinical status of the patient upon arrival.

vi. As discussed in a recent document from the European Associationof CardioVascular Imaging, chest CT is frequently used to confirmCOVID-19 pneumonia and might provide possible synergies of andopportunities for cardiac imaging.16

vii. It can be considered to integrate the protocol alongside CCTA inorder to exclude or confirm an ACS in COVID-19 pneumoniawhere elevated troponins are common.

viii. Medication of NSTEMI patients should follow the usual practice. Inpatients undergoing specific COVID-19 treatments, some interac-tions have been reported between lopinavir/ritonavir, antiviraldrugs, and cardiovascular drugs. Lopinavir/ritonavir may inhibit 63CYP3A4 with the need for dosage changes or avoidance of clopi-dogrel and ticagrelor and direct oral anticoagulants such as apixabanand rivaroxaban. Lopinavir/ritonavir also influence statin metabol-ism; therefore, atorvastatin and rosuvastatin should be administeredat the lowest possible dose.3

In terms of protection, two scenarios are relevant: direct patientcontact with or without the risk for aerosol generation. Invasive pro-cedures carrying a direct risk of aerosol generation are resuscitation,intubation, transoesophageal echocardiography (this should be lim-ited and alternatives should be taken into account such as serial trans-thoracic echocardiography, CT, or cardiac magnetic resonance),16

and any procedures during which the patient can become unwell,with active coughing or vomiting.

Key messages• It is essential to differentiate type 1 MI from other causes of

troponin elevation and/or ST changes without a coronaryaetiology.

• Initial reduction in STEMI presentations are observed, followed bya surge in late STEMI more frequently associated with cardiogenicshock and mechanical complications.

• STEMI and high risk NSTEMI have to be managed as COVID-19positive, and dedicated entry points in ED as well as in hospitalpathway need to be organized.

• CCTA can be performed as an added protocol in those under-going a CT scan, considered according to local resources.

• Differentiate direct patient contact with or without the risk foraerosol generation procedures.

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.5. STEMI: primary PCI vs.thrombolysis

The COVID-19 pandemic should not compromise timely reperfu-sion of STEMI patients.20–22

In line with current guidelines, reperfusion therapy remains indi-cated in patients with symptoms of ischaemia of <12 h duration andpersistent ST-segment elevation in at least two contiguous ECGleads.22 Concurrently, the safety of HCWs should be ensured.2 Tothat end, and in the absence of previous SARS-CoV-2 testing, allSTEMI patients should be managed as if they are COVID-19 positive.We provide general guidance to address the healthcare system or-ganization and delineate possible pathways for specific STEMI set-tings. The proposed actions are not evidence based, may need to beadapted to meet local hospital and health authority regulations, andmay be subject to change in view of the evolving COVID-19 pandem-ic as described in Tables 1 and 2.

While general measures for healthcare systems on redistributionof hub and spoke hospital networks for cardiovascular emergency2

and reorganization of ER and hospital pathways are described inSections 8 and 9, respectively, the main principles of STEMI manage-ment in the COVID-19 pandemic are the following.

i. The maximum delay from STEMI diagnosis to reperfusion of 120min should remain the goal for reperfusion therapy under the fol-lowing considerations:

a. primary percutaneous coronary intervention (PCI) remains thereperfusion therapy of choice if feasible within this time frameand performed in facilities approved for the treatment ofCOVID-19 patients in a safe manner for healthcare providersand other patients;

b. primary PCI pathways may be delayed during the pandemic dueto delays in the delivery of care (as described in Section 4) andthe implementation of protective measures (up to 60 min—according to multiple experiences);

c. if the target time cannot be met and fibrinolysis is not contraindi-cated, this should then become first-line therapy. Of note, fibrin-olysis should be taken into consideration only if type 1 MI ishighly likely.

ii. As SARS-CoV-2 test results are not immediately available, anySTEMI patient should be considered potentially COVID-19 positive.

iii. All STEMI patients should undergo testing for SARS-CoV-2 as soonas possible following first medical contact irrespective of reperfusionstrategy, at the latest upon admission to the ICU post primary PCI.Until the result of the test is known, all precautionary measuresshould be taken to avoid potential infection of other patients andHCWs.

iv. All physicians involved in the management of patients with STEMIshould be familiar with indications, contraindications, and dosage offibrinolysis, and adhere to established administration protocols(Supplementary material online, Tables S1 and S2).

v. Consider immediate complete revascularization if indicated and ap-propriate (as reported in Table 2) in order to avoid staged proce-dures. This strategy would aim to reduce the need for readmissionsduring the ongoing crisis, limit the risk of exposure of patients andHCWs, as well as minimize hospital stay.

vi. Perform a left ventricular angiogram in patients having an invasiverevascularization procedure in order to evaluate left ventricularfunction. Echocardiography can then be avoided in these patients,

with the exception of those that become haemodynamically un-stable or develop potential post-STEMI complications.16

vii. In the case of mechanical post-STEMI complications, managementshould follow current ESC guidelines, taking into account clinical sta-tus, accepting the need for triage in times of restricted access.

viii. Specific pathways for management of STEMI patients are illustratedin Figure 1.

Key messages• All STEMI patients should be managed as COVID-19 positive• Primary PCI is first-line therapy if it can be performed in a timely

fashion—120 min from symptom onset• Fibrinolysis if not contraindicated can be considered when the

delay is longer• Complete revascularization to be considered if indicated and

appropriate• Left ventricular angiogram instead of echo to evaluate left ven-

tricular function

6. NSTE-ACS: immediate, early,and conservative management

The management of patients with non-ST-segment elevation ACS(NSTE-ACS) should be guided by risk stratification.23 As a generalrule, all patients with NSTE-ACS should undergo testing for SARS-CoV-2 as soon as possible following first medical contact, irrespectiveof treatment strategy, in order to allow HCWs to implement ad-equate protective measures and management pathways (Section 10).

Risk stratification should be based on the criteria as provided byESC guidelines on NSTE-ACS. However, the pathways for these pa-tient groups will be modified according to pressures on the networkand consideration of infection control. Patients should be categorizedinto four risk groups (i.e. very high risk, high risk, intermediate risk,and low risk) and managed accordingly (Figure 2). At variance withESC recommendations, we do not envisage including GRACE riskscoring during the pandemic when COVID-19 status has to be takeninto account. Also, patients with a rise in troponin and no acute clinic-al signs of instability (ECG changes, recurrence of pain) might be man-aged with a primarily conservative approach. The purpose of this re-classification, which remains valid only during the time of theCOVID-19 pandemic, is to unload the healthcare systems and toavoid as much as possible the risk of patient as well as HCW contam-ination in regions with intermediate and high involvement as definedin Section 2.

Patients at very high riskThese patients should be managed as patients with STEMI (see dedi-cated Section 5).

Patients at high riskFor these patients, a medical strategy aimed at stabilization andprompt execution of a SARS-CoV-2 test is recommended, whilstplanning an early (<24 h) invasive strategy. The time of the invasivestrategy may, however, be longer than 24 h according to the timingof testing results. In the case of a positive SARS-CoV-2 test, patientsshould be transferred for invasive management to a COVID-19hospital.

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..Patients at intermediate riskFor these patients, a medical strategy aimed at stabilization andprompt execution of the SARS-CoV-2 test is recommended.

Patients should be carefully evaluated taking into consideration al-ternative diagnoses to type 1 MI, as described in Section 4. In theevent that any of the differential diagnoses seem plausible, a non-invasive strategy should be considered and CCTA should be fav-oured, if equipment and expertise are available.

When there is a positive SARS-CoV-2 test, patients shouldbe transferred for invasive management to a COVID-19 hospital.At times of high demand on the infrastructure and reduced availabilityof cathlabs or operators, non-invasive conservative managementmight be considered with early discharge from the hospital andplanned clinical follow-up.

Patients at low riskA conservative strategy based on non-invasive testing is recom-mended for patients at low risk. A SARS-CoV-2 test is also recom-mended in these patients.

In NSTE-ACS patients with positive troponin and clinical signs ofheart failure, echocardiography may be of importance to justify afaster invasive revascularization procedure.16

Key messages• Very high risk NSTE-ACS should be managed similarly to STEMI• High risk NSTE-ACS should be tested before coronary

angiography• Intermediate risk NSTE-ACS could be evaluated non-invasively, if

feasible with CCTA• Consider adding CCTA protocol to thorax CT scan performed in

COVID 19 patients

7. Cardiogenic shock and need formechanical cardiac support

Cardiogenic shock (CS) is defined as a primary cardiac disorder thatresults in both clinical and biochemical evidence of tissue

Figure 1 Management of patients with STEMI during the COVID-19 pandemic. The figure considers the following potential scenarios: (i) STEMIpatients accessing care through the STEMI network (i.e. by ambulance) should be directly transported to COVID-19 hospitals with 24/7 catheteriza-tion laboratory facilities (cathlabs). If at the time of hospital arrival the dedicated COVID-19 cathlab room is not available, fibrinolysis should be con-sidered. (ii) STEMI patients self-presenting at the emergency department of hospitals with cathlabs should undergo reperfusion in COVID-19hospitals with 24/7 primary percutaneous coronary intervention (PCI) facilities. Otherwise, patients should be transferred. If a timely primary PCIcannot be achieved taking into account an estimated 60 min extra delay due to the COVID-19 outbreak, fibrinolysis should be considered. (iii)Patients with STEMI self-presenting at the emergency department of hospitals without cathlabs should be transferred to COVID-19 hospitals with24/7 primary PCI facilities. If a timely primary PCI cannot be achieved taking account of the extra delay due to the COVID-19 outbreak, fibrinolysisshould be considered. (iv) Hospitalized COVID patients suffering from STEMI should be treated with primary PCI if the COVID-19 hospital has 24/7cathlab facilities. Otherwise, transfer the patient to a COVID-19 hospital with 24/7 cathlab facilities. If a timely primary PCI cannot be achieved,patients should be treated with fibrinolysis. Timely primary PCI as described in the text is a primary PCI performed within 120 min from symptomonset. It is suggested to perform left ventriculography during catheterization.

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.hypoperfusion.24 The severity of haemodynamic compromise rangesfrom being at risk of CS (stage A) to cardio-circulatory collapse, po-tentially requiring rescue mechanical circulatory support (MCS)(stage E).25 Importantly, recent data in such patients demonstrateshock of undetermined aetiology in up to 12% of COVID-19patients.26

Severe cardiac dysfunction in COVID-19-positive patients mayoccur from a number of mechanisms, including myocardial virus lo-calization13 or acute myocardial injury/type 2 MI triggered by imbal-ance of oxygen demand and supply associated with increasedbreathing work and severe hypoxaemia.27

Close monitoring of circulatory parameters and cardiac bio-markers is essential in daily ICU practice, as is the use of heart andlung ultrasound for clinical evaluation. However, to reduce exposureto infection risk for HCWs, comprehensive echocardiography maybe reserved for those patients with high suspicion of cardiac involve-ment such as increased hs-cTn, ECG signs representing ischaemia, orhaemodynamic instability.28,29

Except for viral myocarditis,30 there is limited knowledge regardingthe use of percutaneous ventricular assist devices (pVADs) forhaemodynamic support in previous influenza outbreaks, as morefocus has been placed on respiratory support.31 However, if haemo-dynamic instability persists despite maximal medical therapy, the es-calation to a pVAD has to be considered and patients should betransferred and further managed in expert centres which may offerdifferent choices of MCS.24,32

Intra-aortic balloon pump (IABP)Despite recent guideline recommendations concerning IABP usein CS,20 this method is still widely available in ICUs and mayfind its application24 in STEMI patients with a potentially

increased rate of related mechanical complications during theCOVID-19 pandemic.

Percutaneous veno-venous (VV) or veno-arterial (VA) extracorporeal membraneoxygenation (ECMO)Patients with COVID-19 present a high prevalence of developing se-vere acute respiratory stress syndrome (ARDS) requiring high posi-tive end-expiratory pressure (PEEP) and driving pressure,33,34 thusleading to increased right ventricular afterload and, finally, right ven-tricular failure.35 In the case of refractory hypoxaemia (P/F <80)/re-spiratory acidosis (pH <7.25 with PaCO2 >_60 mm Hg) despiteoptimal medical and ventilator strategy [titration of plateau (<27cmH2O) and driving pressures (<17 cmH2O), pulmonary vasodila-tors, andpronation], VV ECMO should be considered36 also todown-titrate intrathoracic pressure and reduce right ventricularafterload.37 If further haemodynamic support is needed, consider-ation should be given to either a percutaneous oxy-right ventricularassist device (RVAD) or alternatively upgrading to VA ECMO.37

VA ECMO supports both lung and cardiac functions, and is consid-ered the device of choice in COVID-19 patients with haemodynamicand respiratory failure. In addition, an IABP or Impella may be used tomanage left ventricular overdistension in patients receiving VAECMO.33

ECMO-assisted cardiopulmonary resuscitation (ECPR) can beconsidered in carefully selected patients who develop cardiac arrest,considering the likelihood of poor outcomes also due to the consid-erable risk of infection.

Patient and device selection are vital, in particular in the COVID-19 pandemic situation where resources are limited. The aim is to sup-port especially those patients with an acute but potentially reversiblecause, such as myocarditis, pulmonary embolism, and tachycardia-

Figure 2 Recommendations for management of patients with NSTE-ACS in the context of ther COVID-19 outbreak. LVEF = left ventricular ejec-tion fraction; MI = myocardial infarction; NSTEMI = non-ST-segment elevation MI; *estimated glomerular filtration rate <60 mL/min/1.73 m2.**Coronary computed tomography angiography (CCTA) should be favoured, if equipment and expertise are available. In low risk patients, othernon-invasive testing might be favoured in order to shorten hospital stay. It is suggested to perform left ventriculography during catheterization.

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.related or toxicity-related cardiomyopathy before the onset of multi-organ failure.38,39

Key messages• Clinical outcome in CS is even worse in COVID-19 patients (30–

40% vs. 45–50% survival)• STEMI patients in CS should be transferred and further managed

in expert centres which may offer different choices of MCS• IABP may be an option in haemodynamically depressed COVID-

19 patients presenting with STEMI and mechanical complications ifother MCS not available

• Veno-arterial (VA) ECMO support is considered the device ofchoice in COVID-19 patients with haemodynamic and respiratoryfailure

• Impella (or IABP) may be used to manage left ventricular overdis-tension in patients receiving VA ECMO

8. Redistribution of the hub andspoke hospital network forcardiovascular emergencies

Time-dependent emergency healthcare networks are experiencingmajor disruptions after the COVID-19 outbreak, especially in thoseEuropean regions most affected by the pandemic. Regions may becategorized into three groups according to the degree of involve-ment in the pandemic, with subsequent different implications for thehealthcare system as summarized in Tables 1 and 2.

As the pandemic progresses, routine diagnostic and elective inter-ventions are being drastically reduced and services are focusing onhigh-risk patients requiring urgent treatment, as described in Section2. In some European countries, healthcare systems have identifiedspecific COVID-19 hospitals or wards (Supplementary material on-line, Table S3), in an attempt to concentrate and isolate confirmedCOVID-19 patients and to prevent the spread of the virus over mul-tiple hospitals.2 COVID-19 hospitals are usually tertiary hospitals,normally serving as STEMI hubs, with an ICU and 24/7 cathlab activity.To free up these hubs, non-infected patients are sometimes trans-ferred to non-COVID-19 hospitals after acute treatment. Human orlogistic resources may be shared amongst institutions, especiallywhen a hub is temporarily put into quarantine.

With the widespread pandemic, attempts to strictly separateCOVID-19 and non-COVID-19 patients into separate managementpathways and environments might become more challenging. In add-ition, identification of suspected COVID-19 patients is elusive, as itrelies mostly on clinical symptoms or epidemiological assumptions. Infact, 50–75% of subjects positive to COVID-19 may be asymptomat-ic, while the remainder may develop symptoms within the reportedrange of 0–24 days40,41 after contact with the virus. Therefore, allpatients entering time-dependent networks should be consideredpotentially COVID-19 positive, unless ruled out with appropriatetesting, and HCWs should adopt all appropriate protective measuresas described in Section 10. All these patients should be tested assoon as possible, but in the meantime should enter protected, dedi-cated, isolated paths and environments warranting the best availabletreatment (e.g. primary PCI, ICU monitoring, etc.) until infection isruled out. Confirmed COVID-19 patients need to be transferred to

dedicated COVID-19 wards or an ICU. Strategies should be guidedby the availability of transport systems, cathlab facilities, teams, and in-fection control considerations of the local network.

Key messages• In regions with moderate and heavy involvement in the pandemic,

the STEMI network has to be reorganized• ACS should be directed to COVID-19 hospitals with 24/7 cathlab

facilities• Strategies should be guided by the availability of transport systems,

cathlab facilities, teams, and infection control considerations of thelocal network.

9. Reorganization of emergencydepartment and hospital paths

This section contains examples for the reorganization of ED andhospital pathways in regions with moderate or heavy involvement(Figure 3).

The ED might be divided into areas for receiving patients that are‘hot’ or suspected COVID-19 and ‘cold’ for patients with otheremergencies. It would be ideal to have a dedicated entry point andtriage for cardiovascular emergencies.2 These areas should be dis-tinct, with separate teams providing care in each of these areas toprevent the risk of cross-contamination. It should be clear regardingthe entry point for each of these areas with rapid triage upon arrivalto ensure the patient is in the correct place. In the setting of a sus-pected STEMI, the hospital should ensure a dedicated entrance toallow immediate treatment with prompt reperfusion.

Following assessment, if the patient has tested positive forCOVID-19, or the infection remains a possibility, the patient shouldbe transferred to a specific area, where care can be provided by staffappropriately trained and with the relevant personal protectiveequipment (PPE) as described in Section 10. It is recommended tofollow full infection control measures when transferring patients forthe protection of the staff and all other patients within the hospital.As patients may be acutely unwell, critical care areas again should bedivided to prevent cross-contamination. Those patients who do notrequire critical care might be cohorted in clearly demarcated ‘hot’areas, ensuring that these areas are not in close proximity to at-riskpatients, such as those who may be immunocompromised.

There should also remain some critical care ‘cold’ areas for thosepatients who may require invasive therapies, including those with un-stable cardiovascular disease. Maintaining separate areas throughoutthe hospital for both COVID-19-positive and -negative patients willhelp to minimize additional infection and the related hospitalmortality.

Key messages• The ED should be reorganized in order to have different entry

points for cardiovascular emergencies and hot (COVID-19) andcold (non-COVID) areas

• Hospital pathways should be redesigned in order to allocatepatients according to their admission symptoms and SARS-COV-2test result in COVID-19 and non-COVID wards and ICU accord-ing to their clinical presentation and stability

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.10. How to prepare cath labs andguarantee protection tohealthcare providers: generalindications for staff and roommanagement

It is recommended to separate HCWs into groups to potentially re-duce exposure and therefore limit the operators who may berequired to be in quarantine at the same time. It is suggested to iden-tify one dedicated cathlab for the treatment of suspected or con-firmed COVID-19 cases.17–19,42–46 The dedicated cathlab has to befully equipped with all interventional materials stored inside

(catheters, guidewires, angioplasty balloons, stents, etc.), ideally be-hind closed cupboard doors, avoiding entry and exit of the staff mem-bers during the procedure. A daily checklist for the presence ofadequate PPE in the cathlab and for a dedicated crash cart (Figure 4;Supplementary material, Table S4) should be completed.47,48

Donning and doffing proceduresAll HCWs have to be routinely trained in the correct and appropri-ate use of PPE. Donning/doffing (the process of putting on andremoving PPE) manoeuvres should be supervised by a trained obser-ver who reads the correct sequence of PPE use to minimize the riskof contamination (Table 3).

Figure 3 Reorganization of emergency department and hospital paths during COVID-19 pandemic in hub centres for an STEMI/NSTEMI network.In a hub centre for an STEMI/NSTEMI network in the emergency department, dedicated different entry points and triage as well as hospital pathwaysand wards are advocated for patients with diagnosed or suspected of having COVID-19 because of symptoms (blue), cardiovascular emergencieswithout diagnosed or suspected COVID-19 (red), and other emergencies without diagnosed or suspected COVID-19 (yellow). All patients admittedto the cardiovascular emergency triage for ACS should receive SARS-CoV-2 testing. Patients with STEMI or very high risk NSTEMI should be imme-diately referred to the cathlab, while those in the other NSTEMI risk categories should be referred to a dedicated chest pain unit before SARS-CoV-2testing results are available. Patients should be further managed according to SARS-CoV-2 testing. The red dotted lines highlight the dedicated unitsfor the management of ACS patients.

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..What to do before patient arrival to thelab (suspected or confirmed COVID-19patient)i. Notify the area receiving the patient of any necessary additional pre-

cautions over and above those for the treatment of the COVID-19patient.

ii. Maximize coordination to avoid steadying in waiting areas.iii. Ensure during movement of the COVID-19 patient there is appropri-

ate space around the patient to reduce the risk of cross-contamination of other patients/HCWs.

iv. Pre-alert the anaesthesiologist to consider elective intubation, If ap-propriate, this should be performed before arrival of the patient inthe cathlab

v. Only the personnel involved directly in the cathlab should remain inthe room. Identify an appropriately trained supervisor for donning/doffing for all team members prior to arrival of the patient.

vi. Patients can wear a surgical mask during transfer and entry to thecathlab (when breathing spontaneously).

What to do during interventionalprocedure in a suspected or confirmedCOVID-19 patienti. Keep the door closed with signage to prevent entry.ii. Avoid entry and exit from the room of the cathlab personnel (dedi-

cated COVID-19 cabinet recommended).

iii. Minimize contact with the surfaces—change external gloves (or addanother pair of gloves) before any new contact (e.g. before opening atray).

iv. Keep the procedure as simple as possible, whilst maintaining goodclinical care for the best outcome and in order to minimize hospitalstay and readmission rates.

What to do after the COVID-19 patientleaves the cathlabi. Keep the door closed.ii. Supervised doffing. If no filter zone is available, doffing could be done

inside the lab, when the patient has been transferred away. The facialrespirator should be removed outside the cathlab.

iii. Do not squeeze contaminated materials into the waste container inorder to avoid aerosol generation.

iv. Dispose of all waste according to protocols and reprocess any re-usable PPE.

v. Personnel to leave the room.vi. All members should be monitored for fever and any respiratory

symptoms for 14 days following the exposure with a COVID-19 pa-tient (or follow local protocols).

What to do in aerosol-generatingproceduresIn procedures that are aerosol generating (i.e. endotracheal intub-ation or transoesophageal echocardiography) or at high risk for

Figure 4 Individual protection equipment for cardiac health workers of cardiac invasive facilities in suspected or diagnosed COVID 19 patients.

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.

requiring an aerosol-generating procedure (e.g. haemodynamic in-stability), recommendations are the same as for patients with con-firmed COVID-19, regardless of the degree of suspicion of infection.

What to do in patients withoutsuspected COVID-19 in local areas withhigh infection burdenFollow the general rules of preventing infections in the cathlab, espe-cially in patients transferred from the ED.

In procedures involving manipulation of the airway and/or oe-sophagus, or in those patients at risk of requiring this manipulation(e.g. unstable patients), recommendations are the same as those inpatients with confirmed COVID-19.

i. In patients requiring intubation and mechanical ventilation or cardio-pulmonary resuscitation, extreme care should be taken to apply pre-ventive measures due to the high risk of droplet release.

ii. In those who may require transoesophageal echocardiography, man-ual ventilation, intubation, or any other type of airway manipulation,we recommend that the approach to infection prevention should bethe same as that used in patients being tested for COVID-19 infectionor with confirmed infection.

Key messages• It is recommended to dedicate at least one cathlab for the invasive

treatment of suspected or confirmed COVID-19 patients• It is crucial to establish clear pathways for COVID-19 patients in

the cathlab at each intervention centre• Only HCWs involved in the procedure should remain inside the

cathlab; cathlab doors should be kept closed at all times.• A surgical mask for the patients, and complete PPE for HCWs

involved in the cathlab intervention• All HCWs have to be routinely trained in the correct use of PPE

(donning and doffing)

11. Conclusions

There is no single solution for all invasive services and networks inthe COVID-19 pandemic, and there will be a variation of the restric-tions according to the stage of the crisis. At the onset, before the ex-ponential rate of infections reduces bed and infrastructure capacity,there may still be the opportunity to treat the majority of ACSpatients, whilst through the peak of infections in some hospitals therewill simply be no capacity to treat more than the most acute andhighest risk ACS patients. The strategies and measures outlined inthis statement are intended to help with making these difficult deci-sions and organizing the service for maximum efficiency, whilst pre-serving the safety of the HCWs.

The vast experience gathered in the affected areas cannot be sum-marized in a single document, and we point to the power of socialmedia and web-based reports that should be consulted regularly fornew commentaries, developments, and exchange. The EuropeanSociety of Cardiology has established a webpage summarizing adviceon all aspects of cardiology relating to COVID-19: https://www.escardio.org/Education/COVID-19-and-Cardiology. Practical advice andcase examples as well as interactive exchange of experience can be

found on the PCR-online pages https://www.pcronline.com/Cases-resources-images/Zoom-on/COVID-19

We are all moving together as an interventional community in thischallenging time and, by helping each other with advice and exchange,we should hopefully make it through this crisis knowing we can pro-vide the best possible care for our patients in the most difficultcircumstances.

Table 3 Sequence of donning and doffing of PPE

Donning PPE sequence

1. Remove any personal items

2. Put on the lead apron

3. Put on a first disposable gown

4. Gather the necessary PPE and check for their integrity

5. Perform hand hygiene with soap and/or hand gel/rub

6. Put on the proper disposable respirator N95 or FFP2 standard

(FFP3 available for anaesthesiologist and nurse helping on airways

manoeuvres)

7. Put on hair cover

8. Put on shoe covers

9. Put on googles and/or face shield avoiding any interference with

the respirator.

10. Perform hand hygiene

11. Put on the first pair of gloves

12. Put on a gown (sterile or not according to your role in the cath

lab) not using the inside tie

13. Put on a second pair of gloves (over cuff), sterile if needed.

Doffing PPE sequence

Inside the cathlab (or in the filter zone if available):

1. Wait until patient is out of the room; close the door.

2 .Perform hand hygiene over the gloves

3. Peel off gown and gloves together and roll inside, slowly and

carefully, avoiding aerosol generation 4. If gloves are removed sep-

arately, touch only the external part (use glove-in-glove or beak

technique)

5. Perform hand hygiene (over the internal gloves) 6. Remove face

shield and/or googles avoiding contact with face and eyes and dis-

pose of them safely or put in a separate container for reprocessing

7. Perform hand hygiene (over the internal gloves)

8. Remove hair cover and dispose of it safely

9. Remove shoe covers and dispose of them safely

10. Perform hand hygiene (over the internal gloves)

11 .Remove internal gloves and dispose of them safely

12. Perform hand hygiene

13. Step out of the cathlab and immediately close the door.

Outside the cathlab:

14. Put on another pair of gloves

15. Remove facial respirator without touching the front side of the

respirator

16. Remove the gloves

17. Remove lead apron

18. Perform hand hygiene with soap and water and alcohol gel/rub.

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.Supplementary material

Supplementary material is available at European Heart Journal online.

AcknowledgementsAlessandro Beneduce, MD, Rafael Romaguera, MD, and FrancescaZiviello, MD are thanked for their help in manuscript preparation.

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